Accreditation Slide Show

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AAAHC The Accreditation Association
Selecting an Accrediting Body Carolyn
Kurtz, JD July 23-24, 2007
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Why is Accreditation Sought?

• Public Recognition
• Marketing
• Regulatory Compliance
• Reimbursement
• Consultative Guidance
• Quality Improvement
• Specialty Society Requirements
• Increasing Consumer Awareness
• Media Influence

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About AAAHC

• Private, independent, not for profit
• Established 1979 28 years dedicated exclusively
  to quality improvement in ambulatory care
• Board of Directors 17 National Health Care
  Organizations representing the many facets of the
  ambulatory environment
• Over 3,000 currently accredited organizations
• More than 312 trained surveyors, most of them
  physicians, from all types of health care
  organizations
• Our Board expertise, committees task forces
  examine every issue related to ambulatory
  accreditationevery new trend impacting on
  accreditation or quality of care.

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Mission Statement

• AAAHC is committed to maintaining its position
  as the preeminent leader in developing standards
  to advance and promote patient safety, quality,
  value and measurement of performance for
  ambulatory health care through peer based
  accreditation processes, education and research.

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What is unique about AAAHCs Services...

• With 28 years of experience accrediting all types
  of ambulatory organizations, AAAHC is recognized
  throughout the country by regulators, health
  plans, insurance companies, and virtually all
  other stakeholders.
• AAAHC cares about the organizations it accredits.
  Its standards are high but so is its
  sensitivity to the needs of accredited
  organizations.
• AAAHC surveyors are expertsthey are practicing
  health professionals making AAAHC accreditation a
  true form of peer review.
• AAAHC accreditation is cost-effectiveefficient
  and reality-based. The accreditation process
  focuses on care at the patient-provider level
  where real quality improvement can occur.
• AAAHC reviews and makes revisions of our
  standards necessary to meet the changes in and
  demands of the marketplace.

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Why should a facility choose AAAHC

• Because AAAHC exists to help ambulatory care
  organizations succeed in raising the quality of
  care.
• AAAHC relies on collaboration with health care
  organizations to raise the standard of care and
  achieve buy-in from our accredited community.
  Accredited organizations own the standards and
  are proud they can comply with them.
• AAAHC established the Institute for Quality
  Improvement (IQI) to provide value-added
  assistance to accredited organizations in quality
  measurement and improvement.

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Philosophy and Approach

• Focus Quality of care at the provider/patient
  level
• GoalImprove and enhance the quality and
  effectiveness of health care in ambulatory
  settings
• StandardsDesigned to promote excellence,
  professionalism and patient safety
• Survey Process FocusAssure compliance with
  published standards through an educational and
  consultative approach

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Types of Organizations Surveyed

• Since its founding in 1979, AAAHC has conducted
  surveys in nearly every type of ambulatory
  organization, including
• Ambulatory Surgery Centers Clinics
• Single Multi-Specialty Group Practices
• Endoscopy Centers
• Managed Care Organizations (HMO, IPA, PPO)
• Dental Group Practices
• University and College Health Services
• Lithotripsy Centers
• Community Health Centers
• Occupational Health Centers
• Immediate/Urgent Care Centers
• Office-Based Surgery Centers
• Indian Health Centers
• Pain Management Centers
• Networks of Groups of Health Care Organizations
• Military Health Care Facilities

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AAAHC Board Representation

• American Academy of Cosmetic Surgery
• American Academy of Dental Group Practice
• American Academy of Dermatology
• American Academy of Facial Plastic and
  Reconstructive Surgery
• American Academy of Ophthalmology
• American Association of Oral and Maxillofacial
  Surgeons
• American College Health Association
• American College of Gastroenterology
• American College of Mohs Surgery
• American Academy of Obstetricians and
  Gynecologists

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AAAHC Board Representation

• American Gastroenterology Association
• American Society of Anesthesiologists
• American Society for Dermatologic Surgery
• American Society for Gastrointestinal Endoscopy
• Foundation for Ambulatory Surgery In America
• Medical Group Management Association
• Society for Ambulatory Anesthesia
• Public MemberChris Strayhorn, MD - National
  Association of Community Health Centers

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Continual Growth FY 00/01 05-06
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75 Growth inAccredited ASCs
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Recognition Expansion

• Federal/National Level
• Centers for Medicare Medicaid Services
• Deemed Status for ASCs and MedicareAdvantage
  (HMOs/PPOs)
• U.S. Air Force
• Contract to accredit 65 ambulatory clinics
  world-wide
• U.S. Coast Guard
• Contract to Accredit all ambulatory clinics
  Contiguous 48 states, Alaska, Hawaii, Puerto Rico
  

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Recognition Expansion Continued

• State Level
• - Collaborative Agreement with New York Dept.
  of Health for ASCs
• -   Granted deemed status to survey ASCs by
  Indiana and Texas Depts. of Health and Ohio
  following initial licensure
• -   Approved to review ASCs adverse drug events
  programs as required by Utah Department of
  Health
• -   Recognized in all states requiring OBS
  accreditation
• - Granted deemed status by California to survey
  OBS settings to meet state requirements

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The AAAHC Accreditation Program
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Program Fundamentals

• A Peer-based program beginning with the
  development of standards through to the
  accreditation decision process
• Emphasis on Education and Consultation
• All organizations are surveyed by the Core
  standards and applicable adjunct standards

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AAAHC Standards

• Outcome statements that reflect the
  characteristics that AAAHC requires of an
  accreditable ambulatory health care organization.

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AAAHC Standards

• 7 Core Chapters Rights of Patients
  Governance Administration Quality of Care
  Provided QMI Clinical Records Facilities
  Environment
• 16 Adjunct Chapters Chapters are applied
  based on the services provided by the
  organization

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Surveyors

• 312 volunteer surveyors nationwide
• Professionals who are actively involved in or
  have extensive experience with ambulatory health
  care, including
• Physicians
• Dentists
• Registered Nurses
• Administrators
• Surveyors receive initial credentialing/training
• Re-trained/Re-credentialed every 2/yrs
• Oversight provided by Surveyor Training and
  Education Committee

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Pre-Survey/Application Process

• Submit Application and Supporting Documentation
• Examples of Documentation
• Organizational history
• Mission statement
• Articles of Incorporation/Bylaws
• Statement of Patient Rights/Responsibilities
• Credentialing Policy
• QI Program Description
• Emergency Plan

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Types of Surveys

• Early Option
• Consultative
• Initial
• Random
• Discretionary
• Medicare Deemed Status

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On-Site Survey Includes

• Opening Conference
• Tour and Inspection of Facility
• Review of select clinical records, QI projects,
  credentialing files, organizational polices
  procedures, and other documentation to support
  compliance with the standards
• Individual Interviews
• Summation Conference
• Areas that meet and do not meet standards or
  require improvement
• Consultative advice on how to improve performance
• Experiences and/or resources that illustrate best
  practices

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Post Survey Process

• Survey team submits completed Survey Report
• Staff reviews the report for completeness and
  consistency
• Accreditation Committee reviews the Survey Report
  and supporting documentation and makes decision
  regarding accreditation
• Organization receives accreditation decision
  letter

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Accreditation Decisions

• Three year
• One Year
• Six Months
• Deferral
• Denial/Revocation

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Commitment to Quality
AAAHC Institute for Quality Improvement

• The AAAHC founded the AAAHC Institute in 1999 to
  provide opportunities for ambulatory health care
  organizations to participate in and learn about
  clinical performance measurement and improvement.
• Thirty studies have been completed to date
• Studies are designed to examine processes and
  outcomes at the point of care
• Quarterly workshops and annual conferences offer
  ongoing opportunities for education on quality
  improvement "how to" and problem solving.

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AAAHC The Accreditation Association
Phone [phone] Web site www.aaahc.org E-mai
l info_at_aaahc.org